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PRIVATE ONSITE WASTE TREATMENT SYSTEMS Burnett County <br /> Visconsin ( POWTS) Property Address:a(0a(yo <br /> Department of Commerce INSPECTION REPORT , <br /> Safety and Buildings Division (ATTACH TO PERMIT) <br /> Sanitary Permit No: <br /> GENERAL INFORMATION <br /> Personal information you provide may be used for secondary ses[Privacy Law,s. 15.04(1 Xm)] <br /> 24-72 Liq <br /> Permit Holler's Name: Ci' I Village own of: State Plan Transaction IDM: <br /> CST BM Elev: Insp BM Elev: BM Description: Parcel Tax No: <br /> /UO•C) AWL. /nl RED OAK /6' N 15 <br /> TANK INFORMATION ELEVATION DATA <br /> TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV <br /> Septic SKA W Boo ffo S. Benchmark /, 75 lob 75 foo• C7 <br /> Dosing <br /> Aeration Bldg.Sewer Sv 96-67 <br /> Holding St/Ht Inlet S 94.23 <br /> TANK SETBACK INFORMATION St/Ht Outlet S. 7*7 95.98 <br /> TANK TO I P/L WELL BLDG VENT To ROAD Dt Inlet <br /> AIR INTAKE <br /> Septic MO ^/6t 1033' — NA Dt Bottom <br /> Dosing NA Installation <br /> Contour <br /> Aerafion NA Header/Man. <br /> Holding Dist. Pipe 7. 9 � <br /> PUMP/SIPHON INFORMATION Infiltrative <br /> Surface 8 /D 93.G5 <br /> Manufacturer Demand Final Grade <br /> Model Number GPM <br /> TDH Lift Friction Loss System Head TDH Ft <br /> Forcemain Length Dia I Dist To Well <br /> DISPERSAL CELL INFORMATION <br /> DIMENSIONS Width tp Length 7Z No of cells Y Type of System Manufacturer: <br /> ConVe�ro"^,/ LEACHING <br /> SETBACK P/L BI well tJNwM of Nav CHAMBER <br /> INFORMATION Waters Model Number: <br /> CELL TO >i00 x 75' //o, <br /> DISTRIBUTION SYSTEM X Pressure Systems Only <br /> Header/Manifold Distribution Pipe(s) X Hole Size X Hole 04servation Pipes <br /> Length Dia Length 70 Dia Spac — Spacing Yes ❑No <br /> SOIL COVER <br /> Depth Over Depth Over Depth of Seeded/Sodded Mulched <br /> Cell Center I Cell Edges Topsoil ❑Yes ❑No ❑Yes ❑No <br /> COMMENTS: (Include code discrepancies,persons present,etc.) <br /> Permit Posted? (Y) N <br /> Schedule 40 Vents and Observation Pipes?(�) N <br /> Cover Material: SPAR <br /> Effluent Filter Manufacturer SwTyBE Model F:�To 822 <br /> Components Not Inspected: <br /> Plan revision required?O Yes O No 1;�Jcoos ? d Z 3 1 <br /> Use other side for additional information Date POWTS spector's SignatuCert No <br />